Many companies in the 1930’s to 1990’s created slogans for their specific cigarettes and used celebrities to gain popularity on their advertisement. They make smoking appear modern and fashionable, influencing audience with coolness and suaveness when lighting a cigarette. Companies back then have little knowledge on the health risk issue on tobacco and doctors were unable to prove the negative health effects of smoking. Often the advertisements used children or even doctors to brand their product and drew more new customers. Singapore has banned tobacco advertisement on television, newspapers and magazines on 1 March 1971 and ceased advertisements on radio and neon signs on 31 December 1970. Yet we still have a high numbers of smokers in the population today. Adult smokers find it cool and suave when they smoke as it make themselves look much more confident and in control. Advertising is a powerful tool, one that plays a large role in whether people decide to start smoking or not. A study by the George Institute of Global Health in 2010 revealed that 80 percent of all smokers live in low and middle-income countries of the Asia Pacific region but actual estimates of the burden of disease due to smoking in the region have yet to be quantified which was obtained by the World Health Organization (WHO). The national prevalence of smoking in the Asia Pacific region ranged from 18-65% in men and from 0-50% in women. The fraction of lung cancer deaths attributable to smoking ranged from 0-40% in Asian women and from 21-49% in Asian men (Alexandra Martiniuk, Crystal MY Lee, Mark Woodward, Rachel Huxley, 2010). In the Straits Times where the health minister shares country’s experience at summit, Singapore is trying to become a smoke-free city, managed to keep the smoking percentage down over past decades. However it jumped up to 14.3 percent in younger smokers aged ranging from 18-29 with significant increase (MFA, 2012).
Why does anyone ever pick up a cigarette in the first place knowing the health risks and cost incurred with smoking? There can be hundreds of reasons why one smokes. Picking up a cigarette habit usually falls in the group of younger teens as they are in their curiosity stage, having peer pressure and influence from their social group. Smoking makes them look cool and mature. Some takes after from their parents and family members. Often teens in their adolescent stage; also adolescent rebellion seeks to get attention. Many teens experiment by smoking a few cigarettes out of curiosity in their peer group and then stop. Unfortunately, many others go on to become regular smokers due to nicotine addiction and social influence. American Cancer Society (2013) mentioned that nicotine (drug found naturally in tobacco) causes pleasant feelings and distracts the smoker from unpleasant feelings. It is as addictive as heroin or cocaine which a person becomes physically dependent on and emotionally addicted to nicotine. About half of these regular smokers will become addicted. Most teenage smokers believe they will quit in the near future and some believes that they will become lifetime smokers. Hence, youth will be most likely to be interested in quitting than adults and if they do make a serious attempt to quit, most are surprised at how hard it is due to the physical dependency which causes unpleasant withdrawal symptoms.
There are many different types of intervention to help smokers in quitting smoking or cut down in their consumption. In today topic, I would like to talk about Motivational Interviewing (MI) technique used as an intervention for smoking cessation. MI is a technique used to promote change in addictive behavior, initially used to treat alcoholism. It is designed to help people to explore and resolve ambivalence about behavior change which incorporated with counseling technique in a non-aggressive and non-confrontational approach. MI concept was developed by Miller in 1983 when he experienced in treating his alcohol abuse clients. Miller (1983) cited that MI approach is defined as a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence. Miller and Rollnick (1995) also suggested that adopting an aggressive and/or confrontational style (as in traditional approaches) is likely to produce negative responses from people (like arguing), which then may interpreted by the practitioner as denial or resistance. Miller (1994) cited that motivation may fluctuate over time or from one situation to another, and can be influenced to change in a particular direction.
Motivational Interview does have a success rate for smoking cessation. A study from The British Journal of General Practice cited by (R Soria, A Legido, C Escolano, et al., 2005) measure the effectiveness of smoking cessation treatment at both 6 and 12 months post intervention showed that the action based on MI was 5.28 times more successful than anti-smoking advice. With the guide from counselor using motivational interviewing techniques can help client to move from the pre-contemplation stage through to the contemplation stage and preparation stage. In order for MI to be effective to help client, intensive MI with more sessions with longer duration is more effective than single or shorter sessions. Counselor needs to know if client is ready to change. Not knowing client’s dilemma or difficulties and offering solution with inadequate rapport establishment in pre-contemplation stage is likely to be unsuccessful. In doing so, counselor is directing the client from pre-contemplation stage to action. Counselor should go through the thinking process with the client. Continued MI techniques and support are needed in the action stage (when the patient stops smoking). MI techniques break down into 5 stages (pre-contemplation, contemplation, preparation, action and maintenance). For most persons, behavioral changes gradually occurs, with the client being unconcerned, ignorance of health risk issues or unwillingness to make a change in pre-contemplation stage moving to considering a positive change (contemplation) and slowly moving to decide and prepare to make a change (preparation). Client’s determination and authentic decision to action on the change requires help to carry out and comply with the change strategies.
In the pre-contemplation stage, client does not even consider changing. Smokers who are “in denial” may think that smoking is not a major problem or issue in their life. Mandated clients may show angst with defensive and resistance behavioral during the counseling process. When dealing with mandated client, counselor has to show empathy and reflect on their response by paraphrasing their statement siding with negative to turn the spot light (resistance) to other area (to shine on client’s agenda). Counselor reflects current view of client’s addiction using reframing strategies technique. Questions and paraphrasing statement such as “Part of you… and yet I wonder…” will makes clients feel validated and understood. When counselor reflects the views back to client, they felt their problems have finally been listened to instead of lecturing them what they need to change. And of course counselor has to take into consideration and be aware not to use reflective responses too early until they have already established rapport with clients.
Counselor has to educate the client about the negative effects of smoking after enquiring with client their concern and decision in smoking while influencing them slowly but surely to increase their motivation. When counselor expresses concern to the client, it naturally creates better rapport and establishes a better relationship with them. (Rollnick et al., 1992) stated that client will be better motivated to moderate their substance use or to abstain (either solely through their own efforts or with the help of a treatment program), if these key persons offer relevant information in a supportive and empathic manner, rather than being judgmental, dismissive, or confrontational. Substance users often respond to overt persuasion with some form of resistance. Counselor should ask question through the eyes of someone else when resistance occurs during this stage as it take away the ownership of their issue when they don’t feel like sharing or elaborate on details. Counselor must never assume that all clients are at preparation/action stage as the tendency to lose this client will be much greater especially when they use over powering words.
When client at pre-contemplation stage agrees that smoking is a problem and considering quitting, he/she has move to the contemplation stage. Discussion will be provided in educating client about the effects of smoking and consider the positive aspects of not smoking on their next return visit. During the contemplation stage, the client understands that smoking is a problem and wants to stop. Counselor at this stage will resolve client’s ambivalence and access positive and negative thinking about smoking by eliciting self-motivational statement to the client that their health will be improve when they quit smoking, allowing a smoke free environment in their house. The family members especially if they have young ones will enjoy quality air at home. When clients show ambivalence on their changes response, counselor should use double-sided reflection technique at this stage by eliciting to client’s response statement: “On one hand you are…, on the other hand you want to quit”. Counselor should ask brain storming questions to elicit clients to say statement on reasons to change. Asking open-ended questions on the “what” and “how”, allow client to express their emotion easily. Getting client to evaluate their life in the present on issues that hinders him/her and asking looking forward to the future question: “What do you like your life to be in 5 years’ time?” bring them hope and motivation. Freedman (1996) stated that effective processes for positive change focus on goals that are small, important to the client, specific, realistic, and oriented in the present and/or future.
Once client agrees with counselor on the benefits of not smoking and has decided to quit, he/she has entered into the preparation stage. Counselor should help client in developing a clear plan for smoking cessation. During the preparation stage, the client will want to quit smoking and makes specific plans and strategies for smoking cessation. That will include setting a quit date and identifying the withdrawal symptoms with client which they may encounter during the smoking cessation process. Client necessarily needs their family and social’s support at this stage for quitting becoming effective. Counselor will also encourage the client to take part in a support group or community or agency program that focuses on smoking cessation.
In the action stage, the clients will stop smoking. Counselor requires maintaining frequent contact with client to follow up and provide support and help as needed when they experience with specific triggers. As the saying by Lao Tzu goes, “Do the difficult things while they are easy and do the great things while they are small. A journey of a thousand miles must begin with a single step.” Finally, the maintenance stage is marked by the client’s continued abstinence from smoking. Relapse to smoking behavior is common. Clients often cycle through the stages of change several times before reaching stable abstinence. Albert Einstein quoted; we cannot solve our problems with the same thinking we used when we created them.
Alexandra Martiniuk, Crystal MY Lee, Mark Woodward, Rachel Huxley (2010). Burden of lung cancer deaths due to smoking for men and women in the WHO Western Pacific and South East Asian regions. In Asian Pacific Journal of Cancer Prevention, Vol 11, 67-72. ISBN 1513-7368 (Print)1513-7368 (Linking) American Cancer Society (2013). “Guide to Quitting Smoking“. Retrieved from http://www.cancer.org/acs/groups/cid/documents/webcontent/002971- pdf.pdf
Freedman, J; Combs, G. (1996). “Narrative Therapy: The Social Construction of Preferred Realities”. New York:Norton.
Markel, Howard (2007-03-20). “Tracing the Cigarette’s Path From Sexy to Deadly”. The New York Times.
Ministry of Foreign Affairs (2012). Straits Times: S’pore aims to make smoke-free the norm. Retrieved from http://www.mfa.gov.sg/content/mfa/media_centre/singapore_headlines/2012/201203/new_20120321.html
Miller WR (1983). Motivational interviewing with problem drinkers. Behavioural Psychotherapy 1983;11:147–172.
Miller WR (1994). Motivational interviewing.III.On the ethics of motivational interviewing. Behavioural and Cognitive Psychotherapy 1994;22(2):111–23.
Rollnick SR, Miller WR (1995). What is motivational interviewing?.Behavioural and Cognitive Psychotherapy 1995;23(4):325–34.
Rollnick, S.; Heather, N.; Gold, R.; and Hall, W.(1992) Development of a short “readiness to change” questionnaire for use in brief, opportunistic interventions among excessive drinkers. British Journal of Addiction. 1992;87:743-754 [PubMed: 1591525]
R Soria, A Legido, C Escolano, et al., (2005) British Journal of General Practice, 2006. Received from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1920717/
Mabel Ang from The School of Positive Psychology